A 21-year-old man was diagnosed with a structural defect in the
bottom part of his brain (a Chiari malformation). He was admitted
to a public hospital for elective surgery to relieve pressure on
the brain (a posterior fossa decompression). A trainee neurosurgeon
met with the patient to discuss the proposed surgery and obtain his
consent. The patient was concerned that there were more risks with
the surgery than he had realised, and he was consequently uncertain
about whether to proceed. Later that day, the patient met with the
consultant neurosurgeon whose care he was under, and after
discussing his concerns further, the patient decided to go ahead
with the surgery. The patient was not told that the surgery would
be performed by two trainee neurosurgeons under the direct
supervision of the consultant.

The surgery was performed the following morning. After 1½ hours
in the recovery ward, the patient was transferred to a special care
unit for the postoperative care of neurosurgical patients. The
patient's neurological observations were checked hourly for the
first 12 hours postoperatively, and then two-hourly. However, his
respiratory rate was not recorded after 5pm on the day of surgery.
There were no issues identified with the quality of the surgery and
initially his recovery appeared to progress as expected.

At approximately 7am the next morning, the nurse who had been
looking after the patient overnight left the unit to give handover.
She reported no concerns. Following handover, the nurse who had
just come on duty entered the unit. The curtains around the
patient's bed space were drawn, and the nurse did not initially
sight him. At approximately 7.30am, the nurse drew back the
curtains and found the patient unresponsive. He was not able to be
resuscitated. The pathologist was not able to anatomically
ascertain the cause of death. The post-mortem report referred to
the possibility of a "functional loss of breathing control while
asleep".

The DHB carried out a Root Cause Analysis, which identified
several concerns, some of which were associated with the unit's
routine practices. A number of changes were made by the DHB as a
result of what happened.

It was held that the patient was not provided with services of
an appropriate standard. There were deficiencies in the service
provided by the DHB, as well as individual members of staff.
Sub-optimal processes and practices in the neurosurgical unit meant
services were not provided by the DHB with reasonable care and
skill. Concerns included: a conflict between the postoperative
monitoring instructions documented for this patient and a generic
ward protocol; a failure to check and/or document the patient's
respiratory rate; that close observation of the patient ceased at
the time of the nursing handover rather than following medical
review; and that morning handover was held in another room.
Collectively, these factors resulted in sub-optimal care being
provided to the patient. This was a breach of Right 4(1) of the
Code.

In these particular circumstances, the patient should have been
informed as to who would be performing his surgery. In addition,
there were some deficiencies in the care provided by individuals.
However, in the circumstances it was found that individual breach
findings were not warranted.